‘Rethinking Suicide’: Expert urges South Dakota audience to challenge assumptions

SIOUX FALLS — The Centers for Disease Control says up to 45% of the people who kill themselves had no history of mental illness.

Psychiatrists and psychologists think 90% of them have such a history.

The disconnect between the two figures is one reason health care professionals need to look beyond their assumptions if they ever hope to reverse the trend of suicide growth in the U.S., according to Thursday’s opening keynote speaker at the second annual South Dakota Suicide Prevention Conference. 

Dr. Craig Bryan, a psychiatrist and research fellow at Ohio State University and the author of the book “Rethinking Suicide,” told the audience of about 500 that many long-held beliefs about what works and what doesn’t aren’t grounded in evidence.

Bryan’s talk at the Sioux Falls Convention Center was part of the kickoff of the two-day summit, which will continue on Friday and includes a host of speakers and breakout sessions. The summit helps mental health professionals log continuing education hours to maintain their licenses, but is also attended by police officers and sheriff’s deputies, educators at the K-12 and collegiate levels, and health care professionals. 

Suicide rates have ticked up across the U.S. in recent years, but South Dakota’s growth rate for the tragic metric is even higher. 

Before Bryan’s address on rethinking suicide prevention began, state Department of Health Secretary Melissa Magstadt presented a series of numbers to illustrate the problem.

• Suicide is the 10th leading cause of death in South Dakota.
• It’s the leading cause of death for those 10-29 years old.
• South Dakota has the seventh-highest suicide rate in the U.S.
• Three South Dakota counties in Indian Country are in the top 1% of U.S. counties for high suicide rates.

“And our American Indian suicide rate is two and a half times higher than our white population,” Magstadt said.

The state has poured millions of dollars – some of it allocated through federal legislation – into telehealth, the expansion of crisis response facilities and trainings, and suicide first aid training since 2020, but the rates remain stubbornly high.

Expert: Challenge assumptions

One goal of the conference was to explore why and to identify strategies that might make more sense. Dr. Bryan said the upward trajectory of suicide rates alongside increased spending on prevention, while more pronounced in South Dakota, tracks in every U.S. state.

“I’ve spent several years now wondering why it is that the trend line goes in one direction, even though we’re doing so much more of the stuff that we believe should be reducing suicide,” he said.

The U.S. is among the 25% of countries worldwide to experience long-term growth in suicide rates, largely because its approach to the problem is founded in false assumptions, Bryan said. 

Focusing on those who survive a suicide attempt, for example, while important, obscures important details about those who don’t survive. This “survivorship bias” is present all across health care.

“If we only focus on the people who survive a health condition or treatment, we might actually draw mistaken conclusions about the efficacy of treatments and interventions,” he said.

With the CDC figures, he said, one could fairly argue that a share of the 45% of suicide victims without a documented history of mental illness likely had issues but never sought treatment. But that alone doesn’t account for the gulf between perception and reality among mental health professionals. It’s partially a bias toward diagnosing mental health conditions for those who arrive in clinical settings, he said, even when the struggles expressed during a session might relate to stress over relationships, finances and the like.

“I think this is one of the sinister assumptions about suicide: that it’s an outcome with mental illness,” he said. “And indeed, I would contend that 90 to 95% of what we do in suicide prevention somehow involves mental health services and treatment.”

Bryan also said that suicide screenings are ineffective tools for preventing suicide, because the idea to commit suicide can often metastasize into a suicide attempt with stunning speed.

The way to tackle the problem of suicide, he argued, is to home in on treatments that are proven, some of which have little or nothing to do with a diagnosis of mental illness.

Asking someone to talk about their suicidal feelings or their suicide attempt before barreling through questions on the frequency of those thoughts and feelings, their self-harm plans and their access to weapons tends to have a greater impact, he said.

Rote screening questions “are great for paperwork and lawyers,” he added, “but it’s terrible for patients.”

Safety planning is more effective than medication or talk therapy in most cases, too, he said, because it puts tangible tools at the disposal of the person at risk. Such a plan, when produced thoughtfully with buy-in from a patient, offers a road map for how to cope with intense feelings and protect people from their worst instincts.

Cognitive behavioral therapy, which leans on coping skills and empowering patients with strategies to recognize and manage difficult emotions in advance, also tends to be more effective than other interventions.

Simply asking about gun storage is vital, he said, even though it can be an uncomfortable topic. It offers the person a chance to think about the potential for danger and who they might turn to if they need to lock their weapons away for a while.

988 counselors engage with callers

A rapport-building approach to conversations is baked-in for the counselors who answer the phones when a South Dakotan calls the 988 suicide prevention line, according to Janet Kittams, director of the Helpline Center and the manager of the state’s 988 system.

Questions that might appear in a scripted screening are eventually explored, but Kittams told South Dakota Searchlight that operators understand that relationship building is key to helping those in crisis.

High schoolers suffer rising mental health challenges, report shows

“We need them to connect with people to establish a rapport, to demonstrate that we care, because that’s what they’re not hearing in their lives,” Kittams said. “They aren’t getting that from someplace else.”

Bryan’s talk of safety planning and “means restriction” – securing weapons and other means of self-harm – caught Kittams’ ear as a topic worth exploring for 988 operators.

“If it’s not easy just to reach over and grab whatever the means are, if you have to go through a lock, you have to get to a safe, you have to go through something to get there, it gives you time to pause and think, and for other people to intervene potentially,” Kittams said.

She also took note of Bryan’s talk of suicide screenings and risk factors. That’s important to keep in mind during prevention training, she said.

“Some people do experience or share the 14 signs, but other people do not,” she said. “So I think it’s important to educate people. It’s not an all-or-nothing type of situation.”